Louisiana and the ACA’s Medicaid expansion

471k have enrolled in expanded Medicaid; Lawmakers consider work requirement

louisiana Medicaid guide


On June 1, 2016, Louisiana residents with incomes up to 138 percent of the federal poverty level became eligible to start enrolling the state’s expanded Medicaid program (Healthy Louisiana), with coverage effective July 1, 2016. State projections were that about 375,000 people would enroll in expanded Medicaid.

As of September 2016, more than 305,000 Louisiana adults had already gained coverage under the expanded eligibility guidelines. By April 2018, that number had grown to 471,115. Of those who have enrolled in Healthy Louisiana under the expanded guidelines:

  • More than 192,000 have received preventive healthcare or new patient services
  • More than 38,000 women have been screened for breast cancer, and breast cancer was diagnosed in 365 of those women
  • More than 22,000 have been screened for colon cancer; more than 7,000 of them have had colon polyps removed, averting colon cancer; 291 have been diagnosed with colon cancer
  • More than 7,400 people have been newly diagnosed with diabetes, and are now receiving treatment
  • More than 19,300 people have been newly diagnosed with hypertension, and are now receiving treatment

These numbers indicate the real-world impact of expanding Medicaid.

Will Louisiana implement a Medicaid work requirement?

In early 2018, Louisiana Governor, John Bel Edwards announced that his administration was “actively working” on ideas for implementing a “reasonable” work requirement for the state’s Medicaid program. Bel Edwards, a Democrat, was the prime mover in the state’s expansion of Medicaid in 2016.

In 2017, Louisiana enacted S.R.163, which requires the Louisiana Department of Health to provide monthly data to lawmakers on a variety of Medicaid-related metrics, including the total number of Medicaid expansion enrollees and the number of Medicaid expansion enrollees who have earned income.

According to H.B.3, which was introduced in early 2018, the state had reported that as of December 2017, enrollment in Medicaid expansion stood at 453,000 people, and “fewer than 284,000” of those individuals had earned income (even before S.R.163 was enacted, the Louisiana Department of Health had been providing detailed, up-to-date reports about Medicaid expansion enrollment, which are available to the public but do not include data about income or the work status of enrollees).

The Louisiana House passed H.B.3 in March, but the bill did not advance in the Senate. It called for a Medicaid work requirement, but had been amended to ensure that people wouldn’t lose access to Medicaid if they didn’t comply with the work requirement.

S.B.77, introduced in the Senate in 2018, would direct the state to seek a waiver from CMS, by January 2019, in order to implement a work requirement for Louisiana Medicaid expansion. The work requirement would apply to people ages 19 to 64, and would exempt pregnant women and people with disabilities, along with other populations that would be described in the waiver proposal. The work requirement could be fulfilled via work, education, community service, caring for minor children, or volunteer activities.

H.B.46, introduced in the House in 2018, would also direct the state to seek a waiver from CMS in order to implement a work requirement for non-disabled adults age 19 to 64 who are enrolled in Medicaid and not caring for a child under the age of one year. Enrollees would have to work, volunteer, or participate in other suitable community engagement activities for at least 20 hours per week in order to maintain Medicaid coverage. Exemptions would be available for various populations, including pregnant women, people with disabilities, and people enrolled in substance abuse treatment.

H.B.735, which passed 97-1 in the House in April 2018 and is now with the Senate, would create a workforce training and education pilot program for “improving employment opportunities and promoting workforce advancement” among people receiving public assistance. Enrollment in the pilot program would be voluntary. Enrollees would receive assistance with job training, job referral, career planning, apprenticeships and other job skills development.

Louisiana was the 31st state to expand Medicaid

On January 12, 2016, newly-inaugurated Governor John Bel Edwards signed his first executive order to start the process of Medicaid expansion in Louisiana. Edwards took office the day before, and had promised that Medicaid expansion would be one of his first actions as Governor.

Prior to June 1, 2016, Medicaid eligibility for adults in Louisiana was unchanged from 2013, and childless adults were ineligible for coverage, regardless of how low their incomes were. That created a coverage gap, since people with income below the poverty level cannot obtain subsidies in the exchange, so they had no realistic access to health coverage until Medicaid was expanded.

SNAP data used for auto-enrollment

About 105,000 of the newly-eligible individuals were expected to be auto-enrolled under a program the state used to identify eligible residents based on their participation in SNAP (Supplemental Nutrition Assistance Program, often referred to as food stamps).

Several states have used similar auto-enrollment programs for Medicaid enrollment, but only for initial enrollment. Louisiana is the first state in the nation to gain HHS approval to use SNAP enrollment to automate the initial Medicaid enrollment process as well as the annual renewal.

The long path to Medicaid expansion

On November 21, 2015, Democrat John Bel Edwards won the runoff gubernatorial election in Louisiana. Edwards supported Medicaid expansion as called for in the ACA, and his win immediately made Medicaid expansion much more likely in Louisiana.

Former Governor Bobby Jindal was emphatically opposed to Medicaid expansion, stating in a 2013 editorial that it would be “bad for Louisiana’s taxpayers and bad for our health care system.” Jindal was not eligible to run in the 2015 gubernatorial race due to term limits, but he has continued to rail against Medicaid expansion, even after leaving office, stating in a Politico article that “Obamacare made millions of able-bodied Americans newly dependent on direct government assistance for their health care” (referring to Medicaid expansion as well as the ACA’s premium subsidies), and expressing his belief that this was a fundamentally bad change.

There was a primary election in October 2015, but none of the four candidates received a majority of the vote. So a runoff election was scheduled for November 21, 2015, with voters deciding between the two candidates who garnered the most votes in the first election (Democratic Minority leader of the Louisiana House of Representatives, John Bel Edwards; and Republican Senator David Vitter).

All four of the primary candidates had previously expressed at least some degree of willingness to accept federal funds to expand Medicaid, although all but Edwards had called for using a section 1115 waiver to craft Medicaid expansion in a state-specific way. Edwards’ support for Medicaid expansion was unequivocal.

In addition, lawmakers in Louisiana passed House Concurrent Resolution 75 in June 2015, which helped pave the way for the expansion of Medicaid. HCR75 allowed hospitals to implement a fee that would generate the revenue needed to pay the state’s portion of the cost of expanding Medicaid (the federal government will always pay 90 percent of the cost, but by 2020, states will be responsible for 10 percent of the cost of covering the expansion population; hospitals tend to support Medicaid expansion, as they face dire budget cuts in states that haven’t expanded coverage). HCR75 gave Edwards until April 1, 2016 to propose a plan to expand Medicaid, but he wasted no time in issuing the Medicaid expansion executive order the day after taking office.

Louisiana HHS Director pushes to keep Medicaid expansion

On January 5, 2016, Edwards named Dr. Rebekah Gee to be the Director of Louisiana’s Department of Health and Hospitals, which is the agency that oversees the state’s Medicaid program. Edwards has said that Medicaid expansion would be one of Gee’s primary tasks, and Gee noted that the state would need to hire almost 250 people to process enrollments and manage the expansion of Medicaid.

Gee also said that Edwards’ administration would focus on working with doctors to ensure that there’s an adequate network of providers who are willing to work with the influx of new Medicaid patients gaining coverage under Healthy Louisiana.

Gee noted that in addition to the state’s portion of the cost of coverage for the newly eligible population, the state also has to pay 25 percent of the cost of hiring the 248 new state employees to handle the additional volume in the Medicaid program. The federal government will pay 75 percent of that cost, but the state’s portion was expected to be $2 million. Gee said that she’s aware of “the budget problem’s that we’re inheriting,” calling them “humbling” but noting that the new administration has plans to deal with the budget issues.

The Louisiana Department of Health and Hospitals has also had to work to ensure ongoing state funding for Louisiana’s charity hospitals, which lawmakers restored in May 2016, despite lawmakers’ concerns that not enough was being done to eliminate waste and contain costs.

Do I qualify for the Medicaid?

Medicaid.gov publishes this guide to help you figure out if you may qualify for Medicaid. As of June 2016, eligibility levels for Louisiana Medicaid are:

  • Children ages 0-18: 212 percent of the federal poverty level; children with family income between 212 percent and 250 percent of FPL are eligible for the Louisiana Children’s Health Insurance Program (LaCHIP)
  • Adults: 138 percent of the federal poverty level.

Individuals who receive Supplemental Security Income (SSI); who are elderly, blind or disabled; or who meet certain other guidelines also qualify for Medicaid. Visit Louisiana.gov for more information.

How do I sign up for Medicaid?

There are several options for applying for Medicaid.

The cost of delaying Medicaid expansion

Because Louisiana didn’t expand Medicaid in 2014 and 2015, Governor Edwards’ administration has said that the state missed out on up to $3 billion in federal funding prior to their acceptance of Medicaid expansion in 2016.

The Kaiser Family Foundation estimates that 364,000 low-income adults became eligible for Medicaid under expansion (although the state pegged the number closer to 375,000, and more than 471,000 had enrolled by April 2018). Kaiser also estimates that the previous decision against expansion left 242,000 Louisiana residents in the coverage gap from the beginning of 2014 until mid-2016. Individuals in the coverage gap have income too high to qualify for Medicaid (before it was expanded), but below 100 percent of FPL and therefore they are not eligible for premium subsidies to help them buy private coverage through the health insurance marketplace.

An Urban Institute study found that the state would spend $1.2 billion over 10 years on expansion. Yet over the same period, if Louisiana had continued to reject Medicaid expansion, the state would have lost out on $15.8 billion in federal Medicaid funding and $8 billion in hospital reimbursements. The financial struggles faced by multiple Louisiana hospitals, including the closure of the Baton Rouge General Medical Center emergency room, are attributed at least in part to the state’s previous decision against Medicaid expansion.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

Louisiana Medicaid

How to apply

You can apply at the Louisiana Medicaid Online Application Center. Apply by phone at 1-888-342-6207. Apply in person at a Medicaid application center, or fill out a paper application.

Who is eligible

Children ages 0-18 with household income up to 212% of FPL; kids with family income between 212-250% of FPL are eligible for the Louisiana Children’s Health Insurance Program. Pregnant women with household income up to 138% of FPL. Parents with dependent children with household income up to 19% of FPL. Visit Louisiana.gov for those who receive SSI or who are elderly, blind or disabled.

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